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Ngokwey Ndolamb
Editor's note
A four-day global conference to share experiences in the use of rapid assessment methodologies for the evaluation and improvement of many different kinds of nutrition and health interventions was convened in Washington D.C.. in November 1990. The meeting included individual presentations and panel discussions of training and communication results. Among the health-related activities to which RAP methods have been applied are programmes concerned with AIDS, epilepsy, yaws, onchocerciasis diarrhoeal disease and family planning and programmes for the elderly. This paper provides a masterly summary of a very complex meeting. A hook based on the conference presentations is in preparation.
Introduction
The richness of presentations and the intensity of discussion at the conference on "Rapid Assessment Methodologies for Planning and Evaluation of Health-Related Programmes." held in Washington. D.C.. 1215 November 1990, make it difficult to attempt any meaningful summary. The diversity of participants and of expectations compounds the difficulty. Indeed, apart front the multiplicity of disciplinary backgrounds (social sciences, health sciences, agricultural sciences, etc.) and professional interests (academics, development planners, programme officers, etc.), there was also a diversity of expectations: some came to exchange ideas about their experience with rapid methodologies, others to learn about these methodologies. some came to discuss rapid assessments or rapid appraisals as a method or technique for data collection and analysis, others to present the results of their use of these methodologies. This diversity of expectations was well illustrated by one participant who asked, "Is this a method-oriented or a problem-oriented conference?"
The methodology itself is named diversely: rapid assessment procedures," "rapid rural appraisals," 'participatory rural appraisals," 'rapid ethnographic procedures," etc. The acronym RAP, standing for "rapid assessment procedures," was reinterpreted variously to capture what different participants considered the essence of the methodology: R for relevant, relaxed, relatively rapid, responsible, role reversals; A for anthropological, appraisal, assessment, action; P for participatory, procedures, practice, etc.
The diversity of participants and expectations partly accounts for discussions concerning the specificity of rapid assessment methodologies. One could hear questions or comments like: "Is this RAP?" "What's RAP about this?" "This is not RAP!" isn't RAP just another name for operations research?" "What's new? This has been done already!" 'What's ethnographic about this'?" "This is a standard method." And so on.
These questions and comments illustrate diverging views of these methodologies. For the sake of simplification, we may distinguish a restricted view and an extended one. The restricted view, claiming its scientificity, considers RAP as a set of well-defined techniques; the extended view on the other hand considers RAP as an approach, even an attitude, and focuses on whatever characteristics it chooses to. Proponents of the restricted view set clear-cut standards to determine what is or is not RAP. They are afraid that if anything can be RAP, the whole methodology might be discredited. Proponents of the extended view tend to suggest that RAP is many things to many people and that what is important is not so much conformity to a particular set of techniques but rather conformity to a general participatory methodology. Needless to say, although these two views are presented here as dichotomous, in fact, they are just two end-points of a continuum.
Diversity within unity
One of the most striking characteristics of qualitative methodologies revealed by the conference is their diversity within a coherent unity. Indeed, whatever phrases are used to name these methodologies, whatever terms are used for the acronym RAP, or whatever views are adopted (restricted or extended), most participants would agree at least on the following basic premisses of these methodologies: the participatory approach, methodological pluralism, and action-orientation.
The participatory approach is at the heart of these methodologies - not only the traditional participant observation of anthropologists, but the actual involvement of the community members themselves in the process of data gathering, analysis, or project design in order to correct the common bias of development ventriloquism when so-called experts speak for community members.
Methodological pluralism is both internal and external. Internally, it refers to a combination and convergence of methods and techniques, very often with synergetic effects. Externally, it is an acknowledgement of other methodologies, of the fact that RAP techniques are not a panacea, that they are just one more tool in the tool box, and thus that we should not consider everything a nail just because we have a hammer.
Action-orientation is the third premise, referring to the imperative of practical application of knowledge obtained through these methodologies. RAP is not only a technique or method for data gathering and analysis; it is also a catalyst for intervention, and can itself be an intervention, through consensus or commitment building or in establishing rapport. From the beginning of any RAP study, there should be a commitment to use the findings, or to take action on the problems identified. The example of the Yanomami Indians, one of the most studied people in the world, who do not benefit from these studies, was cited.
From these three premisses result most of the principles of RAP. Many examples of the use and usefulness of these premisses were given. Examples of mapping, seasonal analysis, ranking, and scoring by community members in India [1] were illustrative of the potentialities of the participatory approach, the idea being to "learn from and with rural people."
The papers presented during the conference are a good illustration of the explosive growth and diversification of rapid assessment procedures mentioned by Cernea, especially with regard to use in various sectors and subsectors: health, nutrition, water and sanitation, rural development, urban services. Topics ranged from coping response to AIDS to apparent food consumption, from assessment of the risk of schistosomiasis to hunger-eradication programmes, from high-risk behaviour among longdistance truck drivers to human-water contacts, watershed management, forestry and credit.
The papers presented experiences and data from more than 20 countries, a sample of the tremendous geographical broadening of rapid assessment methodologies. These methodologies, as one participant put it, know no boundaries. Indeed, they have been used in the United Kingdom in health [2] and in Switzerland and Australia in agriculture.
Constraints and difficulties
Difficulties encountered in the use of RAP or of its results were discussed. Some are institutional. others methodological or ideological. Institutional difficulties have to do with training, reward mechanisms, top-down bureaucratic planning methods, and the macro-level nature of national policies and programmes. As Watson [3] noted for this last issue, "In its focus on in-depth analysis of problems perceived by particular communities, the RAP methodology leaves many seeking to conceptualize and implement national programmes asking about its relevance to them."
Similarly, the sensitivity of the RAP approach to culture and cultural diversity may be at times incompatible with political efforts at nation-building, which often tend to ignore cultural specificities, or in any case do not consider them in national planning, even though regional planning is an accepted strategy in national development. Methodological difficulties include among others the balance between quantitative techniques and qualitative appraisals and the issue of the rapidity of the methodology. In conformity with the methodological pluralism that characterizes RAP, there was a consensus on the "complementary use of qualitative assessment and quantitative survey methods for programme planning and evaluation" [4]. This complementarily between "the quantified bones of the survey with the qualitative flesh of rapid assessment" [5] was compared by one participant to the paradigm of yin and yang, where "qualitative is yang, feminine and soft like the moon, and quantitative is yin, masculine and strong like the sun." Another participant noted that qualitative results are the "flavouring of quantitative results."
On the issue of the rapidity of the methodology, there was a general agreement that RAP is indeed more rapid than traditional anthropological fieldwork or some highly formalized survey methods, and that "the more you RAP, the faster you RAP." However, it was also noted that, in fact, RAP can be long, especially if one considers the initial time put into preparing the assessments or the needed background knowledge of and experience with the communities being studied. The issue is then to know when rapid is too rapid or not slow enough, for the data must not only be "soon enough, but also good enough" [6]. "Rapid but Relaxed" was the title of one of the presentations. This idea is well captured by the Latin saying Festina lente ("Make haste slowly")!
There are also ideological obstacles, mainly related to the attitudes of development planners or experts who still "do not take people seriously." do not 'put people first" [7].
Three gaps
Three main gaps in the use of these methodologies and of the results can be distinguished. There is first the gap between techniques and results. Some presentations focused on the techniques themselves, describing the particular combination of methods used, while others insisted on the results, subsuming the uniqueness of RAP in obtaining them. Not enough presentations explored both the techniques and the results as well as the links between the two. This gap between techniques and the results is partly related to the issue of the main conference focus itself, which, as noted previously, led one participant to ask whether the conference was method-oriented or problem-oriented.
The second gap is the one between method and theory. There is indeed a danger that an excessive focus on methods and techniques will slight the theoretical dimensions of this approach. Yet the method itself is related implicitly or explicitly to theory. whether the theory of the specific sectors or aspects being investigated (farming systems, health-seeking behaviour, socio-cultural change. etc.) or the theory of the method itself (e.g. theories of group dynamics for focus group discussions, ethnoscience or cognitive anthropology for mapping, sampling theory for sampling, etc. ). Without a sound theoretical basis, rapid assessment methodologies may not gain much credibility in the academic world; more importantly, they may not contribute to theory-building or to an effective "re-tooling in applied social investigation for development planning" [8] which has both theoretical and epistemological conditions.
Theory, it seems, is unavoidable. There are no techniques without methodology, no methodology without theoretical orientation. and probably no theory without an ideological bias. It is true that not all RAP practitioners need to have a theoretical knowledge of the techniques they are using. In the same vein, one need not know the theory of electricity before turning on the light. However, it seems reasonable to expect that trainers of trainers, for example, will need to be more conscious of the theoretical background, underpinnings, and implications of what they are doing. If there are acceptable levels of theoretical ignorance for some, a total theoretical nonchalance under the presence of methodological purism is misleading at best.
There is also a gap between the knowledge accumulated and its application. In spite of the fundamental action-orientation of these methodologies, it is not always clear how the results are used or can be used. "So what?" is the ever-present question when it seems that knowledge is not being translated into action. It is not sufficient to know that pregnant women think that taking iron tablets will result in overweight babies and complicated deliveries. The issue is how to put the knowledge to use in MCH services. Similarly, the issue is not to determine whether or not the peasants have cognitive or analytical skills. but rather to use their skills in community development programmes. After all, one participant asked. "What is knowledge if it cannot be replicated either in theory or in action?"
Health eduction seems to be one of the main areas of application of rapid assessment methodologies in health. Although this shows that it is possible to narrow the gap between knowledge and application, the long-term nature of health education and the limited results of most health education programmes raise some questions. More importantly, conventional health eduction, as a strategy of teaching people what is good for them seems at times incompatible with the participatory approach which focuses on learning from the people.
Institutionalizing RAP
The conference also raised the issue of the institutionalization of RAP. Institutionalization is a longterm process involving various actors at different levels and various actions. The actors include not only community members themselves but also the intermediary cadres, the service providers and the top leaders, the decision-makers and the decision-takers. It is particularly important not to ignore the leaders who make decisions on priorities and resource allocation.
It is important to know their information needs and the types of decisions they have to make in order to he able to advise them on the relevance of RAP in policy formulation or programme planning. These actors could be with governments, public administrations, development agencies, private voluntary organizations, etc.
Among the actions needed for the institutionalization of RAP, the application of results is certainly one of the most important, not only because it is intrinsic in the methodology itself but also because the relevance of RAP and of RAP results can be a key element in the institutional adoption of these methodologies. It is also of critical importance to sensitize all of those concerned, decision-makers, service providers, community members, etc., and keep them informed; the people in each one of these categories need to have an understanding of the perspectives and constraints of the others. Central to the institutionalization of RAP is training - training in health or agricultural institutions, training of health personnel, and training of community agents. Even anthropologists themselves could benefit from training in rapid assessment procedures, even though these procedures are largely based on anthropological techniques. Training should also aim at developing local level expertise. In fact, capacity building should be imperative whenever foreign researchers are involved in developing countries. In this context, training of trainers becomes urgent.
The establishment and exploitation of networks of RAP researchers and users is also important for the diffusion of techniques and results, and for information and experience sharing. Effective communication of research results needs to be promoted.
For its institutionalization, RAP needs to become an integral part of the programming process in all its phases - situation analysis, planning. implementation, monitoring, and evaluation.
As I pointed out at the beginning, no summary can do justice to this rich and successful conference. I have indicated some of the key issues that were discussed as well as some thoughts on these issues, especially with regard to the methodological pluralism, the participatory approach, and the action-orientation which are the specificity of RAP methodology. Some of the difficulties, constraints, and gaps in the application of these methods and/or of their results were discussed. Actors involved in and actions needed for the institutionalization of RAP were also examined.
If the conference helped us "to analyse critically our new tools, their strengths and weaknesses, with warm hearts and cold heads" [8]; if it helped us to establish rapport among various qualitative methodologies; if it helped us to adopt an attitude of humility, a greater sensitivity to culture in development, a greater respect for people, and methodological pluralism; if it drew our attention to the conceptual load of the techniques we are using; if it helped us consider that whatever we gather and analyse we must try to apply, then it will have succeeded. For, after all, what is knowledge if it cannot be replicated either theoretically or practically?
References
Production and consumption of foodgrains in India: Implications of accelerated economic growth and poverty alleviation. J. S. Sarma and Vasant P. Gandhi. IFPRI Research Report no. 81. International Food Policy Research Institute. Washington, D.C., USA, 1990.
The past performance and future prospects of Indian foodgrain production and consumption are of considerable importance in third-world and global food considerations. India, which faced food deficits till the mid-1970s, became self-sufficient or marginally surplus thereafter; but, even with this remarkable food-production performance, rapid economic growth and poverty alleviation have not been achieved.
This study of foodgrains in India critically examines past growth and performance in foodgrain production as well as developments in the growth and patterns of foodgrain consumption. It finds that rapid growth in foodgrain production will be necessary but extremely demanding, especially in the context of the dual objectives set by Indian planners - acceleration of economic growth and alleviation of poverty. Within agriculture, these objectives will require not only rapid increase in foodgrain production but even faster growth, through diversification, in the non-foodgrain sector, including livestock production and horticultural crops. in which income elasticities of demand and employment potential are high. However, even an impressive performance may leave foodgrain deficits that will require imports and an appropriate development strategy if accelerated economic growth is to be achieved and poverty alleviated.
Food crops vs. feed crops: Global substitution of grains in production. David Barkin, Rosemary L. Batt, and Billie R. DeWalt. Lynne Rienner Publisher, Boulder, Colo., USA, and London, 1990. 168 pages, indexed.
This small book reflects the conviction of the authors that the proponents of agricultural modernization were often committed to unrealistic models of economic behaviour because they could not understand the position of small-scale farming communities. It is based on research to demonstrate that an alternative approach to understanding trends in world grain production and trade is necessary. While the authors conclude that the balance between food self-sufficiency and comparative advantage currently rests with the commercialization of agriculture, exclusive reliance on either cash crops or food crops is not in the best interest of the people in most regions.
The most space is allotted to a quantitative examination of the major trends in worldwide grain production, consumption, and trade during the past 25 years and covers countries that account for 86% of the total area and 88% of world cereal production. It contains 48 tables as well as appendices giving cultivated area and grain yields for 24 developing countries and the USSR. While food production in developing countries has kept pace with, and frequently exceeded, population growth since 1961, food dependency, as measured by the growth in the value of food imports, has skyrocketed. Many countries that were once net food exporters are now substantial importers.
The attainment of food self-sufficiency has been a major goal of most developing countries. The authors provide a valuable and balanced analysis of the tradeoffs for developing countries of emphasizing food crops or feed crops.
Variability in grain yields: Implications for agricultural research and policy in developing countries. Edited by Jock R. Anderson and Peter B. R. Hazell. Johns Hopkins University Press, Baltimore, Md., USA, and London, 1989. 395 pages, indexed. US$45.
The strongest argument for the ability of developing countries to feed their current and immediately foreseeable populations and close the large gap in crop yields between food-short developing countries is the much higher yields in the more agriculturally advanced countries. Even within both developing and industrialized countries there are large differences in the yields of the more advanced and the less advanced farmers. This book provides abundant evidence in support of this thesis for all who are concerned with agricultural and food policy in developing countries. References are consolidated at the end of the volume.
Resources, institutions and strategies: Operation Flood and Indian dairying. Edited by Martin Doornbos and K. N. Nair. Sage Publications, New Delhi. London, and Newbury Park, Calif.. USA. 1990. 400 pages. Rs 2,951.
Possibly no single development project has received as much attention as "Operation Flood," a cooperative dairying scheme that helps small farmers to produce milk for an assured market. The Food and Nutrition Bulletin has twice published articles (vol. 1, no. 3 (1979), pp. 15-19; vol. 7, no. 2 (1985), pp. 14-20) favourably reviewing the effects of this project on rural poverty in the state of Gujarat, India, and on the availability of milk for the New Delhi market. The nutrition and health of participating families is improved as a result of increased income. The scheme has been so successful that the originator and driving force behind it, Dr. Verghese Kurien. received the 1989 World Food Prize.
The study focuses on the processes of social and economic change associated with the scheme. It complements a companion volume entitled Dairy Aid and Development: India's Operation Flood, by M. Doornbos, F. Van Dorsten, M. Mitra, and P. Terhal, which provides an overall analysis of the international linkages and the rural impacts of the operation. The present volume provides references to many more evaluations and analyses. It is an excellent starting point for those interested in this project as a model or as a case study.
Acceptance, control of and trade in irradiated foods. Division of Publications, International Atomic Energy Agency, P.O. Box 100, A-1400 Vienna, Austria. 1989. 204 pages. 580 Austrian schillings. (ISBN 92-0-010189-5)
This publication - the proceedings of an international conference organized jointly by FAO, WHO, IAEA. and ITC-UNCTAD/GATT and held in Geneva, 12-16 December 1988 - contains a wealth of information about the new technology which is now used in commercial plants in about twenty countries.
The volume discusses the key issues of the wholesomeness of irradiated food: the contribution of the technology to public health, food security, and international trade; the control of the process to ensure its correct application for consumer protection; and the acceptance of irradiated foods by industry and consumers. It includes the "International Document on Food Irradiation" (in English, French, Russian, and Spanish), highlighting the major issues related to the acceptance of irradiated food by consumers, governmental and intergovernmental activities, the control of the process, and trade. Also included are the statements of official participants and observers.
Basic sensory methods for food evaluation. B. M. Watts, G. L. Ylimaki, L. E. Jeffery, and L. G. Elias. International Development Research Centre, Ottawa, Canada, 1989. 160 pages.
This small, clearly written manual is intended to provide a basic technical guide to methods of sensory evaluation, with the needs of scientists in developing countries particularly in mind. It is strongly influenced by the experience of the authors in setting up and implementing sensory-evaluation testing at the Institute of Nutrition of Central America and Panama (INCAP) for the evaluation of beans. It is a comprehensive, practical guide for researchers, students. government control agencies, and local industries. A glossary is included.
Culture, health and illness. 2nd ed. Cecil G. Helman. Butterworth-Heinemann, Stoneham, Mass., USA. 1990. 344 pages, indexed. US$24.95.
This is a text on applied medical anthropology, giving comprehensive coverage to the relationship of culture to health and illness. The chapter on diet and nutrition deals with the cultural diversity of food practices as well as their relationship to nutrition-related diseases. The book is oriented primarily towards British students, but the principles it illustrates are universal.
Impact of helminth infections on human nutrition. Lani S. Stephenson. Taylor & Francis, London, New York, and Philadelphia, 1987. 233 pages.
In poor communities, particularly in non-industrialized countries, both malnutrition and parasitic infections are highly prevalent. They sap the energy of the population, result in much chronic morbidity, and often silently retard the development of each new generation of children. This book illustrates how the impact of helminth infections on human nutrition can best be assessed, reviews the scientific evidence linking the two, and encourages more applied research and further efforts to control helminth infections in malnourished people.
Adipose tissue and reproduction. Edited by R. E. Frisch. Progress in Reproductive Biology and Medicine, vol. 14. S. Karger, Basel, Switzerland. 1990. 142 pages, 33 figures and 7 tables, indexed. SwF 139/DM 166/£58 (UK only)/US$92.75 (USA only). (ISBN 38055-5066-9)
Whenever an animal is too fat or too thin, fertility is adversely affected. Women who have too little body fat because of injudicious dieting, intensive exercise. or both also have delay or disruption of their reproductive ability. The editor argues that this relationship is causal and that a minimum amount of body fat is necessary for menarchy. This multiple-authored book summarizes evidence in support of these conclusions from both clinical and experimental studies.
Nutritional adaptation to new life-styles. Edited by J. C. Somogyi and E. H. Koskinen. Bibliotheca Nutritio et Dieta, no. 45. S. Karger, Basel, Switzerland. 1990. 219 pages, 25 figures and 54 tables. SwF 210/ DM 251/£87.50 (UK only)/US$140 (USA only). (ISBN 3-8055-5183-5)
This report of a symposium of the Group of European Nutritionists, held in Helsinki in June 1989, is a unique compilation of the impact of lifestyles on food-consumption patterns in Europe and of the reasons for changes. It includes six chapters exploring consumer relations towards novel and processed foods in Europe. Five chapters dealing with the nutritional consequences of changes in living conditions and lifestyles are of particular practical interest. A short subject index is included. Similar workshops in other regions would be useful.
Human energy requirements: A manual for planners and nutritionists. W. P. T. James and E. C'. Schofield. Oxford Medical Publications. Oxford University Press, New York, 1990. 172 pages. US$75; £45.
This manual provides sophisticated up-to-date information on human energy requirements in an exceptionally well organized and presented manner with multiple tables and illustrations. It provides an overview of energy requirements and allowances, including the underlying basic principles and the different levels of analysis in estimating requirements. It includes consideration of the impact of urbanization, population structure, and activity patterns on energy allowances and the basis for their estimation for various specific population groups. Adaptation and survival on low intakes and the discussion of the difference between maintenance and survival requirements are well covered. Attention is also paid to emergency feeding and the energy requirements of special groups and of various kinds of individuals.
Appendices provide necessary background data on national population distributions, growth patterns. reference values for weights and heights. and the energy cost of various activities. A new and useful feature is the provision of hardware and software specifications for use in a computerized system, ENREQ, for calculating the energy requirements of populations, based on the methods proposed by the 1985 FAO/WHO/ UNU expert consultation in the report Energy and Protein Requirements. (Queries on the use of ENREQ should be directed to the Food Policy and Nutrition Division of FAO in Rome.) A glossary and a short index are provided.
This book should be available to everyone with a professional need for knowledge of human energy requirements and their practical applications. (A very limited number of free copies are available from FAO for developing-country libraries in countries with foreign-currency problems. )
Principles of nutritional assessment. Rosalind S. Gibson. Oxford University Press, New York, and Oxford, UK. 1990. 691 pages. US$45.
This volume provides coherent and comprehensive descriptions of all aspects of the quantitative appraisal of dietary and nutrient intakes in 152 pages. anthropometric assessment in 108 pages. and the use of laboratory methods in 290 pages. An appendix containing reference anthropometric data by age and sex and the index are useful.
This is a very convenient text for those who need more detail on these topics than is provided in Methods for the Evaluation of the Impact of Food and Nutrition Programmes (Food and Nutrition Bulletin Supplement no. 8, United Nations University Press, Tokyo, 1984). However, it is not an adequate source of guidance for physicians and others concerned with the clinical assessment of nutritional status. Although clinical examination is only of limited value for detecting mild and subclinical malnutrition, the chapter on this topic is too short; clinical examination in both surveys and the assessment of individuals in a clinic or hospital setting should be illustrated and covered more extensively and critically. More reference to the growing literature on the importance of assessing the nutritional status of hospital patients would also have been helpful.
The malnourished child. Robert M. Suskind and Leslie Lewinter-Suskind. Nestlé Nutrition Workshop Series, vol. 19. Raven Press, New York, 1990. 416 pages, indexed. US$48.
This volume examines the metabolic and organic changes that occur in undernourished infants and children and the ways in which these changes can be reversed by appropriate intervention. More than 30 experts from around the world review what is currently known about protein-energy malnutrition and what further knowledge should be sought. The effects of malnutrition on neurological, mental, immune, endocrine, pulmonary, cardiac, gastrointestinal. exocrine, pancreatic, and renal functions are discussed. The findings include changes in amino-acid, carbohydrate, lipid, vitamin, electrolyte, trace-element, and drug metabolism.
The consequences of malnutrition for mental function and development and long-term growth are covered, as are prevention and treatment, although not exhaustively. Research topics for the next decade are also proposed. This is a valuable updating of current knowledge of the impact of protein-energy malnutrition on the young child and how it should be handled.
Women, work, and child welfare in the third world. Edited by Joanne Leslie and Michael Paolisso. AAAS Selected Symposium 110. Westview Press, Boulder, Colo., USA, 1989. 265 pages. US$28.50.
Almost all of the chapters in this book, based on an AAAS special symposium, are concerned with how women in developing countries balance productive and reproductive responsibilities and the health consequences of women's work. They examine whether specific types or patterns of women's work have negative impacts on child welfare. The result is the identification of a number of key relationships and criteria that need to be considered by both economic and health programmes. It is a useful contribution to the growing literature on this subject.
Macroeconomic adjustment and the poor: Toward a research policy. Grant M. Scobie. Cornell Food and Nutrition Policy Program Monograph 1. 1989. Available from CFNNP Publications, Savage Hall. Cornell University, Ithaca, NY 14853. USA. US$8 plus postage and handling (domestic US$1.50, international US$5); LDCs can receive one copy free.